A&E as a symptom, not the disease.

WARNINGThis is a long, boring post on the difficulties facing A&E in the current climate. Complete with the disclaimer that my views are entirely my own and should not be used to represent any organisation that I work for yadda yadda yadda….

ED (as A&E was renamed years ago, in the hope of cutting down the number of accidents that present there that are neither life-threatening, nor emergencies) has become somewhat of a hot topic.

Not a surprise: it is a hugely political system, and we are in an election year. Labour MPs are decrying the Tories’ management of EDs, stating that they have “betrayed patients”; David Cameron has made several glib remarks about EDs being busy, but coping “heroically”, there has been much talk about failure and little offer of solutions. This is because we are focussing on the wrong problem.

Increased waiting times and poor performance in EDs are a symptom of failure of our healthcare system at a much deeper level. The issues are admittedly most obvious when you are sat waiting 5 hours to see a doctor with a broken hip or a breathing problem. However, the root cause of this wait is not solely based on occurrences in ED, nor in a failure of pre-hospital systems to avoid unnecessary admissions.

Below is a brief outline of some of the major factors involved in the ED crisis.

Inappropriate access of services:

Despite what the media will have you believe, inappropriate presentations to Emergency Departments are not a direct result of lazy GPs. Most A&E attendances occur between 9-5, when people’s local GP surgeries are open, often with specifically designated emergency appointments available. It is interesting to note that a patient’s impression that they “would not be able to get a GP appointment” is not proof that they have actually tried. We have the media to thank for this one.

Additionally, advice helplines such as 111 make a valiant effort to point people in the right direction. However, it is incredibly difficult to accurately assess someone over the phone, and they largely err on the side of caution and send people unnecessarily through to ED. This is obviously preferable to the alternative end of the spectrum, but again clogs up the Emergency Department unnecessarily.

Patients do not understand that the ED cannot help you with all medical problems. I would see many people who presented due to (perceived) lack of access to their GP, with stable conditions that needed outpatient investigation. Thanks to the NHS restructuring, putting the burden of budgeting onto GPs, we are no longer allowed to refer in to clinics from ED, and as a result the poor patient has had a wasted trip, an unnecessary 4 hour wait, increased the waiting time for others in the department who may actually require emergency care, and has to go to their GP in the end anyway.

Social care funding:

Cuts to social care funding have led to less support for people at home. Vulnerable adults are therefore left without vital support and end up presenting to ED with entirely preventable falls, infections, and loneliness.

Outreach community services such as district nurses are under increasing pressure. In a report published last year, the Royal College of Nursing cited great difficulty recruiting nurses to these roles. The numbers of nurses are decreasing at a time when the demand for their services is exponentially rising. Patients presenting to ED with dressings that need changing, catheters that need unblocking are entirely preventable with good community care.

“Bed blocking”

A significant contributor to increased waiting times in ED is the lack of available beds in which to put the 1 in 5 attendees that are admitted to hospital. This is due to a number of factors, not least:

Out of Hours investigations (or lack of). Patients admitted to hospitals acutely are often stabilised and managed within 24-48 hours. The remaining tests could often be done as an outpatient – things like CT scans and 24-hour tapes. However, it frequently takes a millennium to arrange these tests once someone has left hospital. As a result, relatively stable people stay longer in order to get faster access to specialist tests. Additionally, when people are admitted on a Friday night, they regularly have to wait until Monday morning for a specific investigation, or to see a Consultant specialist, which clogs up beds.

Delayed discharges. These are due to many factors – patients admitted with acute medical problems are often found unable to cope at home, with discharge back to their pre-admission state impossible. In-hospital teams such as Physiotherapy, Occupational Therapy, Speech and Language etc. are amazing, but implementing the much-needed changes takes a huge amount of time. Most of this is due to workload, and the difficulty liaising between hospital care and community services. Social service teams are frequently understaffed and over-worked, and when someone requires state funding for home adaptations or care packages they might as well spend the rest of their lives in hospital.

Lack of senior staff and training doctors:

Although, as I said above, there is too much attributed to the levels of staffing in ED, there is not enough recognition of lack of senior nurses and doctors in training. The importance of this cannot be overstated. Having a Consultant triaging attendances with the experience necessary to stream patients without waiting for investigations is vital. Having experienced nurses ordering the necessary tests before the doctors see the patient avoids pointless delays whilst you await blood tests and other investigations. Having a higher number of registrars and consultants as compared to junior doctors means better and faster decision-making.

Having doctors in training and nurses on contracts is greatly beneficial to a smoothly run department. The reliance on locum doctors and bank nursing staff means that not only is there less of a team mentality, but there is also a lack of knowledge about how the specific hospital operates. Teaching a new nurse where to locate equipment, how to find the IV medications, where to put the CAS cards when they have done an assessment wastes valuable time. Showing locum doctors how to use the computers, where to assess patients, how to refer to specialty teams wastes valuable time. Doing this over and over, day in day out is exhausting for all involved.

Lack of responsibility for our own medical conditions:

There has been a huge drive forward in recent years with regards to health education. We can no longer say that we are unaware of the dangers of smoking, drinking, over-eating, doing next to no exercise, and using recreational drugs. Our jobs as health professionals is to give people the best possible information about how to live as long and as well as they can. It is up to them how much heed they pay us. I have no problem with people choosing to ignore us – I do most of the above list myself. However, we cannot expect our poor healthcare system to pick up the slack for us. We do not have the right to act surprised when we turn up at an ED unable to breathe/with liver failure/diabetes. We give ourselves complex diseases, which are costly in both money and time to treat, and we clog up Emergency Departments due to our own lifestyle choices. We then complain about how long we have had to wait.

A&E as a political football:

A&E is the most easily measurable indicator of how the NHS is functioning as a whole. The 4-hour target, for good or bad, gives a readily accessible measurement for performance across trusts. The NHS is a great source of national pride; we still have the impression that our healthcare system is the best in the world, unique in its vision to offer free at point of service healthcare to all. This is false. However, as a result of this, the NHS is a huge political item. In the lead up to our election year, we will no doubt hear many more ludicrous statements about how best to manage the NHS, and inevitably how best to operate our Emergency Departments. We don’t leave one system alone long enough to accurately assess its efficacy. As doctors, we are simply trying to do our jobs, treat as many people as humanly possible, and do the best we can for our patients. We can do without the vague political platitudes that exalt us for doing “heroic work” in the face of extreme pressure. We don’t do it for the glory. We need practical change, implementation of legitimate management plans to increase social care funding, to incentivise substantive A&E training posts, to improve communication between primary and secondary care, to aid discharges into the community, to offer 7 days a week scanning, to have proper Consultant cover on the weekends, to employ more district nurses, paramedics, therapists.

There is so much that could be changed for the better. There are so many factors affecting our hospitals, our A&Es, our NHS. Pick one, and move on from there. Stop disagreeing with politicians from different parties for the sake of it. Stop reveling in the disappointments of others. Fix our damn healthcare system before it is too late.